NCLEX questions

A 32 y/o female is 35 weeks pregnant and presents to ED with complaints of right upper quadrant abdominal pain, severe headache, and N/V. Her blood pressure was 145/95 and her labs showed: Platelets- 90,000/mm; AST- 155 U/L; LDH- 650 U/L; Hgb- 10.5 g/dL; Blood glucose 95 mg/dL

Select the two mostly likely immediate actions:

i. Administer IM vitamin K

ii. Begin phototherapy

iii. Prepare for emergency c-section

iv. Give high dose corticosteroids

v. Start Mg Sulfate infusion

iii. Prepare for emergency c-section and v. Start Mg Sulfate infusion

Bowtie: A 32 y/o female is 35 weeks pregnant and presents to ED with complaints of right upper quadrant abdominal pain, severe headache, and N/V. Her blood pressure was 145/95 and her labs showed: Platelets- 90,000/mm; AST- 155 U/L; LDH- 650 U/L; Hgb- 10.5 g/dL; Blood glucose 95 mg/dL

Select the most likely condition

i. Acute fatty liver of Pregnancy

ii. Ectopic Pregnancy

iii. Placental Abruption

iv. HELLP Syndrome

v. Cholecystitis

iv. HELLP Syndrome

Bowtie: A 32 y/o female is 35 weeks pregnant and presents to ED with complaints of right upper quadrant abdominal pain, severe headache, and N/V. Her blood pressure was 145/95 and her labs showed: Platelets- 90,000/mm; AST- 155 U/L; LDH- 650 U/L; Hgb- 10.5 g/dL; Blood glucose 95 mg/dL

Select the two most important parameters to monitor

i. Deep tendon reflexes

ii. Serum bilirubin

iii. Blood glucose level

iv. Urine Ketones

v. Platelet count

i. Deep tendon reflexes and v. Platelet count

A nurse is assessing a 31-year-old client at 35 weeks’ gestation who is being monitored for hypertensive disorders of pregnancy. The client reports a severe headache and upper right quadrant abdominal pain. Her blood pressure is 165/105 mmHg, and labs reveal elevated liver enzymes and a platelet count of 90,000/mm³.

Which actions are appropriate?

1. administer mg sulfate

2. encourage the client to ambulate every hour

3. monitor signs of seizure activity

4. prepare for immediate delivery

5. administer NSAIDS for pain

6. document “normal finding” for Plt count

7. maintain the client in lateral left position

administer mg sulfate, monitor signs of seizure activity, prepare for immediate delivery, maintain client in lateral left position

A 24-year-old client at 30 weeks gestation presents for a routine prenatal visit. Her blood pressure is 142/92 mmHg. She denies headache, visual changes, and epigastric pain. Fetal heart rate is 140 bpm. A urine dipstick shows no protein, and there are no abnormal lab values. Which of the following findings support a diagnosis of gestational hypertension? Select all that apply.

A. New-onset elevated blood pressure after 20 weeks’ gestation

B. Proteinuria of +1 on urine dipstick

C. Absence of severe features like headache or visual disturbances

D. Platelet count of 85,000/mm³

E. Blood pressure of 142/92 mmHg on two separate occasions

F. No previous history of chronic hypertension

a. new onset elevated b/p after 20 weeks gestation

c. absence of severe features like headache or visual disturbances

e. b/p of 142/92 on 2 separate occasions

f. no previous hx of chronic htn

A 28-year-old client who has been diagnosed with severe preeclampsia has been given a loading dose of 6 g of magnesium sulfate intravenously over 30 minutes followed by a maintenance dose of 2 g/hr to prevent seizures. Which of the following symptoms would indicate magnesium toxicity? Select all that apply.

A. Loss of deep tendon reflexes

B. RR of 24

C. Oliguria

D. Mg level of 2.0

E. Dyspnea

a. loss of deep tendon reflexes

c. oliguria

e. dyspnea

A 28 week gestational infant is admitted to the NICU with crackles in the lungs, substernal retractions, nasal flaring, and lethargy. Patient has no oral secretions. Vital signs are: BP 56/36, HR 148, RR 72, SpO2 87% on room air, axillary temperature 36.8°C. The provider diagnoses the infant with respiratory distress syndrome (RDS). What are immediate interventions that the nurse should expect to be included in their care? (Select all that apply)

a. Administering oxygen therapy

b. Frequent stimulation to keep the infant awake c. Bottle feeding to break up crackles in lungs

d. Artificial surfactant

e. Initiating chest physiotherapy (CPT)

a. administering o2 therapy

d. artificial surfactant

A premature newborn in the NICU is diagnosed with moderate patent ductus arteriosus (PDA). The nurse reviews the newborns most recent assessment and lab values: P: 170 RR: 74/min O2 sat: 90% RA BP: 62/40 mmHg Feeding tolerance: poor with frequent regurgitation Loud murmur detected Based on these findings, which nursing intervention/priority is most appropriate?

A. Prepare infant for immediate intubation and mechanical ventilation

B. Increase feedings to maintain adequate weight gain and close the ductus

C. Notify the provider and be prepared to administer indomethacin or ibuprofen

D. Prepare the infant for cardiac catheterization to insert coil or plug within the opening

C. notify the provider and be prepared to administer indomethacin or ibuprofen

The nurse is developing a care plan to reduce the risk of intraventricular hemorrhage (IVH) in a preterm newborn born at 28 weeks. Which interventions should be included (select all that apply)

A. Closely monitor for fluctuations in BP

B. Avoiding clustered care to allow longer rest periods

C. Using slow and controlled IV infusions

D. Administering antenatal steroids before birth E. Maintaining neutral head positioning

A. closely monitor for fluctuations in bp

c. using slow and controlled iv infusions

d. administering antenatal steroids before birth

e. maintaining neutral head positioning

Sarah, a 38 year old pt at 35 weeks gestation with twins from IVF, presents to the prenatal clinic complaining of severe headache and vision changes including light sensitivity since yesterday. Sarah is G2T0P0A1L0. Sarah expresses anxiety about her symptoms due to having lost a previous pregnancy to spontaneous abortion, and the stress of having undergone multiple rounds of IVF. She also states her GERD has been acting up for a “couple of days” with less relief than usual from omeprazole, and that she noticed her ankles and feet were swollen but she thought that was a normal part of pregnancy. Sarah is 5’2” and currently 202 lbs.

The nurse takes Sarah’s VS, performs a physical exam, and takes urine and blood samples for lab testing: HR: 92 BP: 163/112 RR: 19 Temp: 98.9°F Fundal height 35cm. +2 pitting edema bilat LE 3+ biceps reflex bilat 3+ patellar reflex bilat Urine dk amber, clear. Dipstick UA: proteinuria +3. Accuchek: 121 mg/dL

What is the nurse's first priority given Sarah’s symptoms and vital signs? a. Administer prescribed omeprazole for GERD b. Reassure the patient and encourage rest c. Notify the healthcare provider immediately d. Encourage fluid intake to improve renal perfusion

c. notify health care provider

Which of the following best explains the cause of Sarah’s headache and visual changes in the context of her current presentation?

a. Hormonal changes associated with third trimester

b. Cerebral vasospasm and edema associated with preeclampsia

c. Increased cerebrospinal fluid due to pregnancy

d. Worsening anemia causing hypoxia to brain tissue

b. Cerebral vasospasm and edema associated with preeclampsia

3. What interventions can you as the nurse expect to implement due to Sarah’s condition? Select all that apply.

a. Administer Magnesium sulfate bolus.

b. Encourage mobility and take pt on walks around the unit.

c. Implement seizure precautions.

d. Provide a low stimulation environment.

e. Administer NS 0.9% at 150 ml/hr.

a. administer mg sulfate bolus

c. implement seizure precautions

d. provide a low stimulation environment

A 28 year old woman at 30 weeks gestation arrives at the emergency department after falling down the stairs at home. She complains of abdominal tenderness and decreased fetal movement. She has no visible vaginal bleeding and is Rh-negative. The provider suspects a placental abruption and orders fetal monitoring, labs, and observation.

What interventions are appropriate?

A. Continuous external fetal monitoring for at least 4 hours

B. Perform a vaginal exam to check for dilation and bleeding

C. Assessment for uterine tenderness and tone

D. Administration of Rho(D) immune globulin

E. Delay the Kleihauer-Betke test until labor begins

a. continuous external fetal monitoring for at least 4 hours

c. assessment for uterine tenderness and tone

d. administration of rho(D) immune globulin

A 25 year old woman 27 weeks gestation has been diagnosed with iron deficiency anemia. She has been prescribed iron supplements at 325 mg/day. Which of the following statements by the patient indicates the need for further teaching? Select all that apply.

A. My condition is treatable if I take my iron supplements as indicated

B. I’m worried about my baby’s low iron levels

C. If I experience any nausea, I should immediately stop taking the medication

D. This condition adds stress to my heart, so I am at a higher risk for complications related to normal blood loss during labor

E. It is important that I take my medication everyday to control the condition and reduce my risk for complications

b. i am worried about my baby’s low iron levels

c. if I experience any nausea, I should immediately stop taking the medication

A 27 y/o who is 29 weeks gestation (G2P1) comes into a clinic for a follow up for glucose tolerance test after failing the 1 hour test (143). Patient had an unexplained IUFD and has a PMH of obesity and GERD. The nurse takes the patient vitals and gives her a sugary drink: Height: 5’7 weighs 189 lbs HR 93 RR: 13

BP: 119/67 Temp: 98.6 F The results for the 3 hour glucose screening came in and was 165. Based on this finding, the provider diagnosed the patient with gestational diabetes mellitus. The patient is concerned and asks, “how will this affect my baby?”.

What would you educate the patient on?

A. Child has an increase risk for macrosomia; leading to difficult labor

B. Child has an increase risk of thrombocytopenia

C. Gestational diabetes has no effect on the child

D. The have a decrease risk for macrosomia

E. The baby has an increase risk CNS defects

a. child has an increase risk for macrosomia leading to difficult labor

e. the baby has an increase risk cns defects

An 18-year-old pregnant patient at 32 weeks gestation presents with a BP reading of 162/110 mm Hg, 3+ proteinuria on a dipstick, and complaints of a severe headache, visual disturbances, and right upper quadrant abdominal pain. The patient is also experiencing generalized swelling. She reports no seizures

What condition does she have?

a. eclampsia

b. preeclampsia

c. chronic htn

d. gestational htn

b. preeclampsia

An 18-year-old pregnant patient at 32 weeks gestation presents with a BP reading of 162/110 mm Hg, 3+ proteinuria on a dipstick, and complaints of a severe headache, visual disturbances, and right upper quadrant abdominal pain. The patient is also experiencing generalized swelling. She reports no seizures

What 2 actions should the nurse take?

a. Administer 4g IV bolus of magnesium sulfate followed by 2g/h maintenance dose

b. Administer a 1L IV bolus of normal saline

c. Administer anti-hypertensive such as labetalol or hydralazine

d. Encourage the patient to ambulate frequently

a. administer 4g iv bolus of mg sulfate followed by 2g/h maintence dose
c. administer anti-hypertensive such as labetalol or hydralizine

An 18-year-old pregnant patient at 32 weeks gestation presents with a BP reading of 162/110 mm Hg, 3+ proteinuria on a dipstick, and complaints of a severe headache, visual disturbances, and right upper quadrant abdominal pain. The patient is also experiencing generalized swelling. She reports no seizures

What 2 parameters should the nurse monitor?

a. bp

b. u/o

c. blood glucose

d. serum sodium

a. bp

b. u/o

Multiple Choice: You are caring for a 34-year-old G4P3 woman at 30 weeks gestation who is presenting with bright red vaginal bleeding. She reports no pain and fetal movement is normal. Her OB history includes two previous cesarean deliveries. What is the nurse’s initial priority action?

A. Perform a sterile vaginal exam

B. Notify the health care provider

C. Apply continuous external fetal monitoring

D. Administer oxytocin to induce labor

c. apply continuous external fetal monitoring

A pregnant woman at 34 weeks gestation arrives at the labor and delivery unit, reporting a sudden onset of intense, localized abdominal pain. She denies any trauma. On assessment, the nurse notes a firm, boardlike abdomen, uterine tenderness, and dark red vaginal bleeding. What condition should the nurse suspect?

A. Placenta previa

B. Uterine rupture

C. Placental abruption

D. Preterm labor

c. placental abruption

“If my baby is experiencing decels with a prolapsed cord, I may need to go to the OR and have an emergency C section.”

does this require further teaching

no

“If I thik I feel my cord protruding from the vagina, I can gently push the cord back in.”

Does this require further teaching?

yes

“If a prolapsed cord occurs, the most ideal position for me to be in is on my back.”

Does this require further teaching?

yes

“One of the risk factors for experiencing a cord prolapse is having a long cord.”

Does this require further teaching?

no

You are caring for a patient G2P1 who is at 41 weeks gestation and has a current history of gestational diabetes. She is in the second stage of labor and the baby’s head has passed the suprapubic arch, but the provider is having difficulty delivering the rest of the fetus.

What is the potential condition?

a. shoulder dystocia

b. uterine cord prolapse

c. placenta previa

d. uterine rupture

shoulder dystocia

You are caring for a patient G2P1 who is at 41 weeks gestation and has a current history of gestational diabetes. She is in the second stage of labor and the baby’s head has passed the suprapubic arch, but the provider is having difficulty delivering the rest of the fetus.

What two actions do you take?

a. Assist with the McRoberts Maneuver and positioning the client

b. Apply suprapubic pressure

c. Encourage the mother to push using as much force as possible

d. Administer Pitocin

a. assist with mcroberts maneuver and positioning the client

b. apply suprapubic pressure

You are caring for a patient G2P1 who is at 41 weeks gestation and has a current history of gestational diabetes. She is in the second stage of labor and the baby’s head has passed the suprapubic arch, but the provider is having difficulty delivering the rest of the fetus.

What two parameters do you monitor?

a.Monitor client for injury and signs of hemorrhage

b. cervical dilation

c. maternal temperature

d. assess newborn for birth injuries

a. monitor client for injury and signs of hemorrhage

d. assess newborn for birth injuries

Which of the following patients would be appropriate candidates for the use of Pitocin (oxytocin) to induce and augment labor?

A. A patient at 40w3d gestation who is experiencing 6 uterine contractions every 10 minutes for three hours, with some contractions lasting longer than 2 minutes.

B. Elective induction at 38w1d gestation because mother wants to have a Valentine’s day baby

C. A patient at 40w6d gestation with spontaneous rupture of membranes but no cervical dilation progression

D. A patient with gestational hypertension whose baby is showing non-reassuring fetal heart rate patterns

C. A patient at 40w6d gestation with spontaneous rupture of membranes but no cervical dilation progression

A 28 y/o female came in at 40 weeks 1 day asking to be induced. Her bishop's score is as follows: dilation 4 cm, 70% effaced, station 0, and soft and anterior position. What are possible next steps for the patient based on this information? Select all that apply:

A. An induction is not recommended because the bishops score does not indicate a favorable induction of labor

B. An induction is recommended because the bishops score indicates a favorable induction of labor

C. Chemical agents recommended are cytotec or prostaglandin E2

D. Chemical agents recommended are magnesium sulfate, hydralazine, and labetalol

E. Membrane stropping by physician

F. Foley balloon for ripening

b. an induction is recommended because the bishops score indicates a favorable induction of labor

c. chemic agents recommended are cytotec or prostaglandin E2

e. membrane stripping by physician

A 24 y/o female is at 41 weeks gestation admitted to the L&D unit for induction of labor. The healthcare provider orders an IV infusion of Pitocin (oxytocin) to augment labor. After 3 hours of the administration, the nurse observes the following

● Contractions every 1.5 minutes, lasting 100 seconds

● FHR indicates 160 bpm with minimal variability

● Maternal vital signs: BP 135/85, HR 95 bpm, temp 99.5 degrees fahrenheit Which of the following actions should the nurse take next?

a. Increase the Pitocin rate

b. Discontinue the Pitocin infusion

c. Administer oxygen via NC at 5L/min

d. Continue to monitor the patient and fetal heart rate

b. discontinue the Pitocin infusion

The nurse is monitoring a patient who is receiving a Pitocin IV infusion to augment labor and stimulate uterine contractions. What assessment finding by the nurse would indicate that the infusion should be discontinued?

A. Contractions are at 3 minute intervals and last for 55 to 60 seconds

B. Three contractions in a 10 minute period

C. Fetal heart rate of 90 beats per minute

D. The patient reports the contractions are becoming more painful

C. Fetal heart rate of 90 beats per minute

A 32-year-old pregnant woman at 34 weeks gestation arrives at the Emergency Department following a fall from standing and complains of a sudden onset of abdominal pain with moderate vaginal bleeding. The patient was at home when she tripped over her dog and fell onto her abdomen. She appears anxious, and her vital signs are BP: 89/61 mmHg (Low), HR: 120 bpm (High), RR: 24/min (High) on room air. The nurse notes a rigid abdomen, continuous uterine contractions on the fetal monitor, and skin is pale and cool to the touch. The fetal heart rate is 100 bpm (Low) with minimal variability

Highlight the three priority nursing interventions for this patient:

A. Administer oxygen via non-rebreather mask B. Perform a vaginal exam to assess cervical dilation

C. Initiate IV access and administer fluid resuscitation

D. Initiate IV access and collect maternal blood for the McRoberts maneuver

E. Prepare for emergency cesarean delivery

F. Obtain a urine specimen for proteinuria testing

a. administer oxygen via non-rebreather mask

c. initiate iv access and administer fluid resuscitation

e. prepare for emergency c-section

A 32-year-old woman, G3P1A1, presents to the emergency department at 10 weeks gestation with vaginal bleeding and mild cramping. She has no fever, and vital signs are stable. She reports no tissue passage. Ultrasound confirms a viable intrauterine pregnancy, and the cervix is closed on pelvic exam.

What is the condition?

Threatened miscarriage, Inevitable miscarriage, Incomplete miscarriage

threatened miscarriage

Select 2 potential nursing actions:

Instruct patient to maintain pelvic rest,

prepare for D&C procedure,

monitor for increased bleeding or passage of tissues,

administer cytotec.

instruct pt to maintain pelvic rest, monitor for increased bleeding or passage of tissues

2 parameters the nurse should monitor: Amount and color vaginal bleeding, fundal height, presence or absence of fetal heart tones, maternal blood pressure

amt and color of vaginal bleeding, presence or absence of fetal heart tones

A 36-year-old woman, G3P2, with gestational diabetes controlled by insulin is admitted in active labor at 39 weeks gestation. Her most recent glucose level is 65 mg/dL, and she is receiving an insulin drip and D5LR IV fluids. The fetal heart rate is reassuring. The nurse enters the room and finds the patient diaphoretic, shaky, and complaining of dizziness.

What actions are appropriate?

A. Pause the insulin infusion

B. Administer 4 oz of orange juice orally

C. Notify the provider that the patient may need IV glucose

D. Reassure the patient and wait 30 minutes before taking further action

E. Increase the insulin drip rate as per protocol F. Recheck capillary blood glucose in 15 minutes

G. Continue labor assessment and fetal monitoring

H. Discontinue D5LR to avoid worsening hypoglycemia

pause the insulin infusion, administer 4 oz of oj orally, notify provider that pt may need iv glucose, recheck capillary blood glucose in 15 mins, continue labor assessment and fetal monitoring

As the nurse, you have just educated your patient on different methods of contraception and their associated complications. Which statement by the patient would indicate that further education is needed regarding complications of IUDs?

A. “With this method if I choose to remove the device, I will have immediate return of fertility “ B. “After insertion this type of contraception does put me at an increased risk of developing pelvic inflammatory disease, infection, and uterine perforation. I should look out for signs and symptoms of these and contact a provider right away if I experience any of these. “

C. “I should contact my provider if I have abnormal spotting or bleeding”

D. “I should check for my IUD strings after each menstrual period but if they are not present that is okay”

D. “I should check for my IUD strings after each menstrual period but if they are not present that is okay”

A nurse is providing discharge teaching to a client who has just had a copper IUD inserted. Which of the following instructions should the nurse include? Select all that apply.

A. "You may experience heavier periods and more cramping with this IUD."

B. "This device will protect you from sexually transmitted infections."

C. "You should return to the clinic if you develop a fever or chills."

D. "This IUD must be replaced every 5 years."

E. "Check for the presence of the IUD strings after each menstrual period."

A. "You may experience heavier periods and more cramping with this IUD."

C. "You should return to the clinic if you develop a fever or chills."

E. "Check for the presence of the IUD strings after each menstrual period."

The nurse is educating a client on how an IUD prevents pregnancy. Which client statement demonstrates correct understanding of how an IUD works?

A. "The IUD works by releasing hormones that delay ovulation until after the fertile window closes."

B. "The IUD blocks sperm from entering the cervix by forming a plug at the cervical opening."

C. "The IUD releases spermicide directly into the uterus to destroy sperm before they reach the egg."

D. "The IUD affects sperm motility and irritates the uterine lining to prevent fertilization and implantation."

D. "The IUD affects sperm motility and irritates the uterine lining to prevent fertilization and implantation."

28 yo G1P0 female presents to ED with chief complaints of abdominal pain and “feeling warm.” She is currently 34 weeks pregnant with twins. Vital signs taken upon arrival at ED are BP: 120/78, HR: 115 bpm, RR: 20, SpO2: 98% on RA, and temp: 102.1 deg F. The patient’s BMI before pregnancy was below 19.6. Fetal heart rate upon arrival at ED is 172 bpm. She has not received any prenatal care outside of her initial ultrasound at 9 weeks gestation. She notes no significant PMHx, and to her knowledge, has thus far had a “normal pregnancy.” Upon physical exam, she appears uncomfortable, with fundal tenderness noted.

Which of the following is the most likely diagnosis?

A. Acute appendicitis

B. Chorioamnionitis

C. Preeclampsia

D. Placental Abruption

b. chorioamnionitis

28 yo G1P0 female presents to ED with chief complaints of abdominal pain and “feeling warm.” She is currently 34 weeks pregnant with twins. Vital signs taken upon arrival at ED are BP: 120/78, HR: 115 bpm, RR: 20, SpO2: 98% on RA, and temp: 102.1 deg F. The patient’s BMI before pregnancy was below 19.6. Fetal heart rate upon arrival at ED is 172 bpm. She has not received any prenatal care outside of her initial ultrasound at 9 weeks gestation. She notes no significant PMHx, and to her knowledge, has thus far had a “normal pregnancy.” Upon physical exam, she appears uncomfortable, with fundal tenderness noted.

Which added finding would support a diagnosis of chorioamnionitis?

A. Fetal measurements measuring below gestational age

B. A decrease in fetal heart rate to 125

C. Foul smelling amniotic fluid

D. Complaint of occasional fetal movement

C. Foul smelling amniotic fluid

28 yo G1P0 female presents to ED with chief complaints of abdominal pain and “feeling warm.” She is currently 34 weeks pregnant with twins. Vital signs taken upon arrival at ED are BP: 120/78, HR: 115 bpm, RR: 20, SpO2: 98% on RA, and temp: 102.1 deg F. The patient’s BMI before pregnancy was below 19.6. Fetal heart rate upon arrival at ED is 172 bpm. She has not received any prenatal care outside of her initial ultrasound at 9 weeks gestation. She notes no significant PMHx, and to her knowledge, has thus far had a “normal pregnancy.” Upon physical exam, she appears uncomfortable, with fundal tenderness noted.

What are neonatal risks associated with chorioamnionitis that the patient should be educated on? (Select all that apply)

A. Cystic fibrosis

B. Meningitis

C. Sepsis

D. Sickle cell disease

E. Pneumonia

meningitis, sepsis, penumonia

28 yo G1P0 female presents to ED with chief complaints of abdominal pain and “feeling warm.” She is currently 34 weeks pregnant with twins. Vital signs taken upon arrival at ED are BP: 120/78, HR: 115 bpm, RR: 20, SpO2: 98% on RA, and temp: 102.1 deg F. The patient’s BMI before pregnancy was below 19.6. Fetal heart rate upon arrival at ED is 172 bpm. She has not received any prenatal care outside of her initial ultrasound at 9 weeks gestation. She notes no significant PMHx, and to her knowledge, has thus far had a “normal pregnancy.” Upon physical exam, she appears uncomfortable, with fundal tenderness noted.

What statement made by the patient indicates the need for further teaching?

A. “I should just take a Tylenol for my fever and then go home and rest.”

B. “I was at risk for premature rupture due to being underweight and being pregnant with twins.”

C. “I can expect to be on antibiotics both before and after birth.”

D. “I can deliver my babies now to prevent further progression of the infection.”

A. “I should just take a Tylenol for my fever and then go home and rest.”

You are the labor and delivery nurse caring for Maria, a G2P1 at 40 weeks gestation, who is undergoing a spontaneous vaginal delivery. After the fetal head is delivered, the provider announces “shoulder dystocia” as the anterior shoulder fails to deliver. You immediately call for help. The provider begins shoulder dystocia maneuvers while you support the patient and assist with interventions. You document the time of head delivery as 14:36. At 14:39, the provider successfully delivers the baby after performing Rubin’s maneuver followed by a Woods Screw maneuver. The newborn shows signs of mild asphyxia and is transferred to the warmer for resuscitation.

Which nursing action is the most critical immediately following recognition of shoulder dystocia?

A. Explain the situation to the patient and her family

B. Call for additional personnel and note the time of head delivery

C. Encourage the patient to continue pushing with contractions

D. Insert a Foley catheter to empty the bladder

B. Call for additional personnel and note the time of head delivery

Which interventions may be used to relieve shoulder dystocia? (Select all that apply)

A. Apply firm fundal pressure

B. Assist the provider with the Rubin’s maneuver C. Assist the provider with the Woods Screw or Reverse Woods Screw maneuver

D. Place the mother into the Gaskin position (hands and knees)

E. Encourage forceful pushing by the mother

F. Assist in removal of the posterior arm

B. Assist the provider with the Rubin’s maneuver C. Assist the provider with the Woods Screw or Reverse Woods Screw maneuver

D. Place the mother into the Gaskin position (hands and knees)

F. Assist in removal of the posterior arm

Following successful delivery, which documentation is most important for the nurse to include in the client’s chart?

A. The infant’s Apgar scores and weight

B. The patient’s emotional response to delivery

C. The exact time of head and body delivery, all maneuvers used, and staff involved

D. The type of perineal laceration and repair method

C. The exact time of head and body delivery, all maneuvers used, and staff involved

A laboring client at 41 weeks gestation has a history of previous cesarean section. She is attempting to have a vagianal birth after cesarean.The patient complains of severe abdominal pain, followed by intense spontaneous uterine contractions. The nurse notes an overdistended uterus and fetal distress on the fetal monitor.

What is the priority action for the nurse?

a.) Administer high flow oxygen via non-rebreather

b.) Notify the healthcare provider immediately

c.) reposition the client to be side lying

d.) Help the client breath through the contractions

b.) Notify the healthcare provider immediately

A 32-year-old woman, G3P2, is undergoing an emergency cesarean section at 39 weeks gestation due to non-reassuring fetal heart tones. She has no prior medical conditions. Ten minutes into the surgery, the patient suddenly becomes cyanotic, hypotensive (BP 78/40), and develops dyspnea. She begins gasping for air and becomes unresponsive. The surgical team notes that she goes into cardiopulmonary arrest. The diagnosis of suspected amniotic fluid embolism (AFE) is made.

A. Administer oxytocin to promote uterine contraction

B. Start chest compressions and call for code assistance

C. Insert a urinary catheter to monitor output

D. Administer magnesium sulfate to prevent seizures

B. Start chest compressions and call for code assistance

Which of the following findings support the clinical diagnosis of amniotic fluid embolism? (Select all that apply)

A. Sudden onset of hypotension and respiratory distress

B. High fever and leukocytosis

C. Cardiac arrest during labor or delivery

D. Coagulopathy and bleeding from IV sites

E. Gradual onset of shortness of breath over 2 days

A. Sudden onset of hypotension and respiratory distress

C. Cardiac arrest during labor or delivery

D. Coagulopathy and bleeding from IV sites

A 29-year-old G2P1 at 37 weeks presents for a follow-up non-stress test (NST) because she has noticed a decrease in fetal movement over the past 48 hours. She has a history of chronic hypertension and gestational diabetes that she manages well with the help of insulin. Today's NST is nonreactive(meaning the FHR is not showing adequate accelerations). A Biophysical Profile (BPP) is ordered.

The BPP results are as follows: Fetal breathing movements: Absent Fetal tone: 1 slow flexion/extension Fetal movement: 2 movements Amniotic fluid index (AFI): 5 cm and one single pocket >2cm Non-stress test: Non Reactive Based on the BPP score and clinical scenario, what is the most appropriate nursing action?

A. Reassure the client the baby is okay, and schedule routine follow-up in 1 week.

B. Instruct the client to return for a repeat BPP in 48 hours.

C. Prepare the client for immediate delivery and notify the physician.

D. Encourage oral hydration and repositioning to improve fetal movement.

C. Prepare the client for immediate delivery and notify the physician.

A 36 year old female, G2P0, at 17W2D presents to the prenatal clinic for a routine checkup. Family hx for this patient includes an uncle with Trisomy 21, and a grandfather with sickle cell disease. Given this patient's current situation, the provider recommended an amniocentesis. The parents have shared some concerns and anxiety about the procedure. What can the nurse discuss to help ease/inform the patient about the process?

Nursing Diagnosis - choose the most appropriate nursing diagnosis to keep in mind during care for this patient, during and post-amniocentesis

a. Risk for fluid volume deficit

b. Risk for infection

c. Risk for disturbed fetal oxygenation

d. Acute pain r/t fetal positioning

b. Risk for infection

Identify two potential complications of an amniocentesis?

a. Preterm rupture of membranes

b. Nausea and vomiting

c. Miscarriage

d. Placenta accreta

a. preterm rupture of membranes

c. miscarriage

A 36 year old female, G2P0, at 17W2D presents to the prenatal clinic for a routine checkup. Family hx for this patient includes an uncle with Trisomy 21, and a grandfather with sickle cell disease. Given this patient's current situation, the provider recommended an amniocentesis. The parents have shared some concerns and anxiety about the procedure. What can the nurse discuss to help ease/inform the patient about the process?

Identify three appropriate indications for amniocentesis in this patient’s context:

a. Advanced maternal age

b. Routine prenatal screening

c. Family history of genetic disorders

d. Carrier status for a hemoglobinopathy

a. advanced maternal age

c. family hx of genetic disorders

d. carrier status for a hemoglobinopathy

You are the nurse speaking with a 28 year old patient who is G1P0 at 32 weeks gestation. You are teaching her about fetal body movements as part of her antepartum education. Which of the following statements by the patient indicate correct understanding of fetal body movements? Select all that apply.

A. “If I feel a little thump in my lower belly, it could be a kick from their leg.”

B. “If the baby stops moving for a whole day, it is no concern as they are just sleeping.”

C. “Early on I felt flutters, and now I feel strong kicks, that means my baby is growing and active.”

D. “I’ll call my provider if I notice a big decrease in my baby’s movements.”

E. “I can continue to take my prescribed sedatives and they won’t have any effect on my baby and their activity”

A. “If I feel a little thump in my lower belly, it could be a kick from their leg.”

C. “Early on I felt flutters, and now I feel strong kicks, that means my baby is growing and active.”

D. “I’ll call my provider if I notice a big decrease in my baby’s movements.”

A client that is 42-weeks pregnant is admitted to the LDRP floor for labor induction secondary to a post-term pregnancy. The client is on continuous fetal monitoring. Upon the nurse reviewing the fetal monitoring strip, she observes late decelerations with minimal variability. Currently, the client is receiving Oxytocin for the induction. Which of the following nursing actions is the most appropriate?

a.) Encourage the client to ambulate to facilitate labor progression.

b.) Continue monitoring, as this variability is expected in post-term pregnancies.

c.) Discontinue the oxytocin and reposition the client.

d.) Increase the oxytocin rate to stimulate stronger contractions.

c.) Discontinue the oxytocin and reposition the client.

A nurse is caring for a 41 week pregnant patient who is in active labor. The provider notes that the fetus is large for gestational age. The nurse recognizes that the patient is at increased risk for which of the following complications? Select all that apply.

a.) Shoulder dystocia

b.) Polyhydramnios '

c.) Birth trauma

d.) Postpartum hemorrhage

e.) Prolonged labor

a. shoulder dystocia

c. birth trauma

d. postpartum hemorrhage

e. prolonged labor

A 33 year old woman presents at 41 weeks and 6 days gestation for a routine prenatal visit. Her pregnancy has been going well with no complications. Fetal Movements are reported as normal and a non-stress test shows a reassuring pattern. Her cervix is 2 cm dilated, 30% effaced, and posterior. What is the most appropriate next step in her management?

A. Repeat non-stress test in one week

B. Induction of labor using cervical ripening agents

C. Perform a cesarean delivery

D. Continue management until 42 weeks gestation

B. Induction of labor using cervical ripening agents

A 31-year-old woman at 34 weeks’ gestation presents to the obstetric triage unit with complaints of a persistent headache and visual disturbances. On examination, her blood pressure is 168/110 mmHg. Urinalysis reveals 3+ proteinuria on the dipstick. Over the past 24 hours, her urine output has been approximately 450 mL.

What condition does she have

preeclampsia with severe features

A 31-year-old woman at 34 weeks’ gestation presents to the obstetric triage unit with complaints of a persistent headache and visual disturbances. On examination, her blood pressure is 168/110 mmHg. Urinalysis reveals 3+ proteinuria on the dipstick. Over the past 24 hours, her urine output has been approximately 450 mL.

What two actions to take?

a. stabalize mom with labetolol iv

b. administer o2

c. prevent seizures with mg sulfate iv

d. administer insulin

a. stabalize mom with labetolol iv

c. prevent seizures with mg sulfate iv

A 31-year-old woman at 34 weeks’ gestation presents to the obstetric triage unit with complaints of a persistent headache and visual disturbances. On examination, her blood pressure is 168/110 mmHg. Urinalysis reveals 3+ proteinuria on the dipstick. Over the past 24 hours, her urine output has been approximately 450 mL.

What two parameters to watch?

a. fetal heart rate

b. emergency c-section at bedside

c. NST, uterine monitoring, sx of uterine rupture

d. CBC, creatinine, BUN, uric acid, coag panel, blood pressure, urinalysis

a. fetal heart rate

d. CBC, creatinine, BUN, uric acid, coag panel, blood pressure, urinalysis

A 23 year old patient at 39 weeks 5 days comes in (G4 P1 T1 A2 L1) for augmentation of labor after being sent home 2 days ago d/t cervix dilation only being at 2 cm without progression for 10 hours. Upon examination she has only increased to 3 cm dilated. The provider has placed an order to start the patient on pitocin. As the nurse, what are some considerations when giving this prescribed medication? Select all that apply.

A. Monitor for uterine contractions more than 5 contractions in 10 minutes

B. Establish baseline of vital signs for patient

C. Place the patient in a supine position to maximize uterine blood flow

D. Monitor for signs of uterine rupture, especially in patients with a previous C-section

E. Notify provider if FHR is 155

F. Titrate Pitocin slowly, starting with a low dose

A. Monitor for uterine contractions more than 5 contractions in 10 minutes

B. Establish baseline of vital signs for patient

D. Monitor for signs of uterine rupture, especially in patients with a previous C-section

F. Titrate Pitocin slowly, starting with a low dose

A 24 year old female comes into her OBGYN with a chief complaint of abnormal vaginal discharge and pain in her lower abdomen. She states that her last menstrual cycle ended a few days ago. Her vitals signs show an oral temperature of 100.9 degrees fahrenheit, Blood pressure of 118/74 mm Hg, HR of 101 bpm, and 16 respirations per minute. During a pelvic exam, the provider notes cervical motion tenderness. The patient has a recent history of Chlamydia that was not treated. Based on this assessment, which condition should the nurse suspect?

Pelvic Inflammatory Disease (PID)

Human Immunodeficiency Virus (HIV)

Herpes Urinary Tract Infection (UTI)

PID

A 27 year old G2:P1:L1:A0 woman, 12 weeks pregnant comes into the OBGYN clinic with complaints of muscle aches and fatigue, not felt in her last pregnancy. Her vitals upon examination are 100.7 oral temperature, 86 BPM, 18 RR, and 124/76 blood pressure sitting. She denies any recent contact with sick individuals, and states she has been home alone taking care of her cats and 13 month old, getting some spring cleaning done while her husband is away on a business trip. This patient denies any new sexual partners, denies any abnormal vaginal discharge, abdominal pain, vaginal/oral sores, and vagianl redness/itching. What is your primary concern for the cause of this patient's symptoms?

A. Syphilis

B. Herpes Simplex Virus 1

C. Toxoplasmosis

D. Gonorrhea

C. Toxoplasmosis

A 19-year-old female presents to the clinic reporting increased urinary frequency and dysuria for the past week. She also reports a new onset of mild, intermittent lower abdominal discomfort and yellowish vaginal discharge. She states she has a new sexual partner in the last two months and reports inconsistent condom use. Her vital signs are: oral temperature 100.4°F (38.0°C), blood pressure 116/72 mm Hg, heart rate 102 bpm, and respirations 18 breaths per minute. Based on this assessment, which of the following is the most likely diagnosis?

A. Herpes Simplex Virus (HSV)

B. Trichomoniasis

C. Chlamydia

D. Urinary Tract Infection (UTI)

C. Chlamydia